Which All-Ceramic System Is Optimal for

Anterior Esthetics?
Frank Spear and Julie Holloway
J Am Dent Assoc 2008;139;19S-24S

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Which all-ceramic system is optimal
for anterior esthetics?
Frank Spear, DDS, MSD; Julie Holloway, DDS, MS
entistry has undergone a
D revolution in the last 30
years, not only with regard
to the introduction of new
materials and techniques,
but also with regard to the scientific
evidence supporting their clinical appli-
cations. Land1 introduced all-ceramic
crowns in 1903, but the material was
weak, the fabrication technique compli-
cated and the choice of luting agents
limited.
EVOLUTION OF ALL-CERAMIC
MATERIALS
McLean2 introduced alumina-reinforced
porcelain jacket crowns in the mid-
1960s. About 10 years later, research
began to be published documenting the
success—or lack thereof—of all-ceramic
crowns.3 By the mid-1980s, the litera-
ture showed that anterior porcelain
jacket crowns had a 25 percent chance
of failing in vivo by 11 years; the failure
rate was even higher in the posterior
regions.4 Fortunately, significant
advances in materials and techniques
have occurred in the last 30 years that
justify the routine use of all-ceramic
Copyright © 2008 American Dental Association. All rights reserved.
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ABSTRACT
Background. As ceramic materials for dentistry evolve
and patients’ demand for esthetic restorations increases, prac-
titioners must keep up with the science as well as the demand.
The authors offer guidance to the practitioner in selecting the
appropriate all-ceramic systems for crowns when faced with
different esthetic demands.
Conclusions. Clinicians should reserve dental ceramics
with high translucency for clinical applications in which high-
level esthetics are required and the restoration can be bonded
to tooth structure. Ceramics with high strength tend to be
more opaque and pose a challenge when trying to match
natural tooth color, but they can mask discoloration when
present.
Practice Implications. Knowledge of the optical
properties of available ceramic systems enable the clinician
to make appropriate choices when faced with various esthetic
challenges.
Key Words. All-ceramics; esthetics; crowns; veneers;
restorative materials.
JADA 2008:139(9 suppl):19S-24S.
Dr. Spear is a founder and director, Seattle Institute for Advanced Dental Education, Seattle.
Dr. Holloway is an associate professor and associate director of the advanced prosthodontics
graduate education program, The Ohio State University College of Dentistry, 305 W. 12th Ave.,
Room 3005-U, Columbus, Ohio 43210, e-mail “holloway.3@osu.edu”. Address reprint requests
to Dr. Holloway.
JADA, Vol. 139 http://jada.ada.org September 2008 19S
 preparations with sub-
gingival margins, these
patients were faced with
the potential risks of
recession, exposure of
the margin, discolored
gingivae and pulpal
involvement. These
classic metal-ceramic
restorations required
Figure 1. All-ceramic and metal-ceramic crowns. Translucent unlayered (left to right): Dicor (Dentsply, not only extensive tooth
York, Pa.; no longer on the market), IPS Empress Esthetic (Ivoclar Vivadent, Amherst, N.Y.), OPC (Pen- reduction, but a highly
tron Ceramics, Somerset, N.J.). Opaque layered: In-Ceram Alumina (Vita Zahnfabrik, Bad Säckingen, skilled master techni-
Germany), In-Ceram Spinel (Vita Zahnfabrik), Procera Zirconia (Nobel Biocare, Göteborg, Sweden).
Metal-ceramic crown with porcelain labial margin and conventional metal-ceramic crown. cian to achieve excellent
esthetics.

restorations in dentistry today. MATERIALS OPTIONS

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One of the most significant of these changes
occurred in 1983 when Horn5 and Simonsen and
Calamia6,7 independently introduced acid-etched
ceramics to create the bonded porcelain veneer,
one of the most successful restorations when
bonded primarily to enamel. With the advent of
dentin adhesives in the early 1990s, porcelain
restorations with significantly higher bond
strengths than those that had been available pre-
viously became possible.8,9 This prompted many
practitioners to forego metal-ceramics and use
bonded ceramics in clinical situations in which
they had never before been used—sometimes suc-
cessfully and sometimes unsuccessfully. A chal-
lenge still exists in that the dentin/adhesive bond
is not as durable or predictable as the enamel/
adhesive bond.10
Major strides in technology permitting routine
use of all-ceramic restorations are the improve-
ment and scientific innovations in the ceramic
materials themselves. High-strength core
materials containing alumina, zirconia, zirconia-
toughened alumina, magnesium aluminate spinel
and lithium disilicate have been introduced and
clinically tested. Laboratory technicians
(ceramists) then apply esthetic veneering
ceramics over these core materials to create a
final, esthetic restoration.
The other change that has occurred in the use
of all-ceramic restorations has been societal atti-
tudes concerning esthetics. Before the early
1980s, people in the entertainment industry were
primarily the only patients who requested elec-
tive esthetic dental procedures. With the only
treatment option being full-mouth rehabilitation
involving the use of complete-coverage crown
Modern all-ceramic systems can be categorized
broadly into two groups: those that are translu-
cent and those that consist of an opaque, high-
strength core onto which esthetic layering
ceramic must be applied to achieve a natural
appearance (Figure 1). Examples of translucent
materials are conventional sintered feldspathic
porcelain fabricated on refractory dies or plat-
inum foil, pressable ceramics (for example, IPS
Empress Esthetic, Ivoclar Vivadent, Amherst,
N.Y.) and some of the in-office machinable
ceramics made via computer-aided design/
computer-aided manufacturing (for example,
Vitablocs Mark II, Vita Zahnfabrik, Bad
Säckingen, Germany). Examples of opaque lay-
ered materials are nonmetallic restorations made
with alumina, zirconia or lithium disilicate used
as high-strength core materials (for example, IPS
e.max, Ivoclar Vivadent; Procera, Nobel Biocare,
Göteborg, Sweden; In-Ceram, Vita Zahnfabrik;
Lava, 3M ESPE, St. Paul, Minn.; and Cercon,
Dentsply Ceramco, York, Pa.).
Properties. As a general rule, the two groups
of all-ceramic systems have distinctly different
properties in several areas. With regard to tooth
reduction, clinicians can use the translucent
materials with more conservative tooth prepara-
tions compared with the opaque, layered systems.
Optically, the translucent materials usually are
more esthetic than the layered materials. Most
translucent restorations must be bonded to
improve their predictability, while layered resto-
rations do not have this sensitivity to choice of
luting agent.11
Because of these differences, dentists can use
most opaque layered materials for traditional

20S JADA, Vol. 139 http://jada.ada.org September 2008

Copyright © 2008 American Dental Association. All rights reserved.
 A B
Figure 2. A. A central incisor fractured in an automobile accident without any pulpal involvement. B. The remaining tooth preparation
is between 2 and 3 millimeters in height. C. The final restoration is a translucent unlayered (pressed ceramic) crown bonded to achieve
acceptable retention.
crown or bridge restorations, while they can use
translucent materials for full-coverage or more
conservative partial-coverage bonded restora-
tions. We can best summarize these differences as
esthetic but weaker versus stronger but more
opaque, a dichotomy that drives the process of
selecting all-ceramic materials.12
Restorative needs. Dentists should base
their choice of material on the requirements of
the tooth being restored. For purposes of sim-
plicity, we can group restorations into four major
categories: porcelain laminate veneer restorations
that replace primarily enamel, partial-coverage
restorations that replace enamel and dentin, con-
ventional complete crowns that cover acceptably
colored dentin, and complete crowns that cover
discolored dentin or metal posts that must be
masked.
PARTIAL ENAMEL REPLACEMENT
The most conservative of all indirect restorations
essentially replace enamel with minimal, if any,
preparation into dentin. These restorations are
useful when the overall tooth color is pleasing
and the restorative goal is to place a new, more
pleasing external surface on the tooth without
changing the tooth color significantly.13,14 Because
the enamel thickness of a natural tooth varies
from 0.4 millimeters on the facial aspect in the
cervical one-third to 0.8 to 1.0 mm on the facial
aspect in the incisal one-third, true enamel
replacement restorations typically are 0.3 to
0.5 mm thick and require minimal preparation.15
In general, some tooth preparation is desirable to
allow for ideal cervical emergence contours.16,17
Because of the ceramic thickness needed for
enamel replacement restorations, dentists should
use only translucent unlayered materials.
In addition to the low possibility of pulpal irri-
tation, margin placement is another advantage of
enamel replacement restorations. The ultrathin,
Copyright © 2008 American Dental Association. All rights reserved.
C
highly translucent ceramic that makes changing
color difficult with these restorations also allows
them to have invisible supragingival margins.15,18
This allows conservative margin preparation
short of the proximal contact or incisal edge and
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helps maintain gingival health.
DENTIN AND ENAMEL REPLACEMENT
As desirable as the conservative nature of enamel
replacement restorations may be, many teeth
simply cannot be treated minimally. Situations
involving large interproximal restorations, tooth
malposition, tooth discoloration, wear or fractures
may require a restoration that involves the
removal of more tooth structure but does not
necessitate a conventional complete-coverage
crown. When the clinician must replace both
dentin and enamel but will not alter the occlusion
or color, translucent ceramics still are the
materials of choice, because of their excellent
enamellike appearance and ability to be bonded to
natural tooth structure.
COMPLETE CROWN AND ACCEPTABLY
COLORED DENTIN
In general, the reasons to use an all-ceramic,
complete-coverage crown for an anterior tooth
include replacement of an existing crown; the
tooth structurally requires that the lingual sur-
face be prepared; the occlusion requires a signifi-
cant change so that lingual coverage is needed;
and large proximal areas of decay are present or
the patient has pre-existing restorations. This is
the one restoration for which clinicians may find
it difficult to decide whether to use translucent
materials or opaque, layered materials, because
both may work equally well. In general, the deci-
sion will be based on the need for high strength
owing to the lack of anterior guidance or the pres-
ence of parafunctional habits, the amount of tooth
reduction required, the laboratory’s preference
JADA, Vol. 139 http://jada.ada.org September 2008 21S
 retain the restoration. By
choosing an adhesively
bonded, translucent
ceramic, the dentist
might be able to use as
little as 2 mm of vertical
preparation height
without the need for addi-
tional foundation restora-
A B tions19,20 (Figure 2).
Figure 3. A. A discolored central incisor crown preparation. B. A translucent unlayered restoration COMPLETE CROWN
at try-in. Note that even though the technician thought it had been opaqued adequately, the dark
color of the tooth structure shows through.
AND DISCOLORED
DENTIN OR METALLIC
POST

A highly discolored ante-

rior tooth presents an

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esthetic challenge. In
such cases, the dentist
will need to use a restora-
tive technique capable of
re-creating the natural
A B color of dentin and then
overlay the tooth prepara-
tion with a more translu-
cent material to achieve
an esthetic final
appearance.
To achieve this,
authors have advocated
several approaches.21-24
One method21 advocates
that clinicians use rela-
C D tively translucent
Figure 4. A. A patient needing veneer restorations to restore the worn lateral incisors and canines ceramics, which have the
and crowns to replace the central incisor crowns. B. The cervical portion of the tooth preparation has greatest potential to be
been prepared an additional 0.3 millimeters to allow for opaque composite to be placed. C. Even
though an opaque layered zirconia crown is used, opaqueing the cervical portion prevents the dark
affected adversely by the
preparation from showing through. D. The final restorations are sintered feldspathic veneers on color of the dark prepara-
teeth nos. 6, 7, 10 and 11 and layered zirconia-based crowns on teeth nos. 8 and 9. tion, but also use an
opaque cement to mask
and whether the clinician wishes to cement or the discoloration. This technique can be suc-
adhesively bond the restoration. cessful, but often it is the least predictable solu-
For teeth with normally colored preparations, tion, because there is no way for the dentist to see
translucent materials enable clinicians to reduce the final color until the restoration is luted. This
less tooth structure (typically 1.0 mm), create becomes difficult for the technician, who must
esthetic margins when they are supragingival or estimate the impact that the tooth preparation
equigingival, and achieve a predictable bond to color and cement will have on the final restora-
the restoration itself, because sintered feldspathic tion color (Figure 3).
ceramics and pressable ceramics are etched A far more predictable approach is to use a
easily. This can be a particular advantage when crown with a more opaque core that is less
an anterior tooth is fractured, because a tooth affected by the preparation color.25,26 The layered
with a traditional cemented restoration might not ceramic systems with more opaque cores are well-
have adequate resistance and retention form to suited for the treatment of discolored teeth. The

22S JADA, Vol. 139 http://jada.ada.org September 2008

Copyright © 2008 American Dental Association. All rights reserved.
technician can see the TABLE
final restoration color
during fabrication,
Clinical situations.
because preparation VARIABLE PARTIAL PARTIAL COMPLETE COMPLETE CROWN
COVERAGE COVERAGE CROWN COVERING
color has little impact ENAMEL ENAMEL COVERING DISCOLORED
on the seated restora- REPLACEMENT AND DENTIN ACCEPTABLY DENTIN OR
ONLY REPLACEMENT COLORED DENTIN METALLIC POST
tion. When using
Amount Minimal As needed; Circumferential, Circumferential,
these restorations for of Tooth (0.3-0.5 mm*), does not 1.0-mm chamfer 1.2- to 1.4-mm
discolored teeth, the Reduction in enamel involve lingual chamfer
only surface
clinician must ensure
a reduction of 1.2 to Margin Supragingival Supragingival Supragingival or Subgingival
Placement or equigingival equigingival
1.4 mm on the facial
aspect, and he or she Strength None, no Low, few Depends on Depends on
Requirements occlusal forces occlusal forces presence of ante- presence of
should use subgin- encountered encountered rior guidance, anterior guid-
gival margins to avoid parafunctional ance, parafunc-
habits tional habits
an unesthetic cervical
All-Ceramic Requires Requires Translucent or Requires opaque
appearance. Clini-

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Material of translucent translucent choose opaque ceramic
cians also should use Choice ceramic ceramic ceramic if
greater strength
these materials when needed
the need arises to Cementation Adhesive Adhesive resin Adhesive resin Adhesive resin
cover a metal post and resin necessary or conventional or conventional
core that cannot be necessary luting agent luting agent

removed27 (Figure 4). * mm: Millimeters.

CONCLUSION modality based on scientific and clinical evidence. N Y J Dent 1983;

We have described the possible types of anterior
restorations and the ceramic materials of choice
for them. It is clear that the requirements for
optical properties, tooth reduction, margin place-
ment, strength and method of placement (bonded
versus cemented) vary for different clinical situa-
tions. Is there a single material that can be used
in all situations? The closest are the translucent
systems, either sintered feldspathic or pressed
ceramics, owing to their ability to be bonded to
tooth structure, as well as to their translucency.
How do dentists choose the material to use, par-
ticularly in the anterior region? First, we recom-
mend that they take into consideration the labo-
ratory’s experience and expertise. Second, we
advise them to refer to the table to best address
the clinical situations encountered. ■
Disclosure. Drs. Spear and Holloway did not report any disclosures.
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